Hereford Physical Therapy and Sports Medicine

Initial Evaluation History Sheet

Name : Physician: Occupation/ Activity/Sports: Date: Diagnosis: Age:

Date of onset / injury / surgery How did you injure yourself? (Circle) Fall Explain Have you had this injury before? (Circle) Please explain any previous treatment you have had for this injury Y N Overuse At Work Sports Unknown

Have you had any x-rays, CAT scans, MRIs, or other diagnostic tests for your recent disorder? (Circle) If yes, please explain the findings as you understand them

Do you have now, or have you ever had, any of the following? (circle) Diabetes High Blood Pressure Heart Condition Pacemaker Chronic Headaches Kidney Problems High Cholesterol If you circled any of the above items, please explain Are you taking any medications -Including over the counter medicines, vitamins or herbal remedies? (Circle) If yes, please list : Anxiety/Depression Arthritis Hernia Dizziness Seizures Pregnant Bone Disease Osteoporosis Fractures Bowel/Bladder issues Cancer Previous Surgeries

Do you have any allergies? (Circle) If yes, please list :

Hereford Physical Therapy and Sports Medicine

Do you have pain? If so, in what area is your pain? Y N

Pain Level on scale 0 - 10

No Pain

0 1 2 3 4 5 6 7 8 9 10

Emergency Room Pain

At best __________ Nature of Pain Frequency

At Worst ____________ Sharp Shooting Constant

Average ____________ Burning Numbness Intermittent Tingling

Dull achey

Occasional

What activities are the most difficult for you at this time:

What is your goal for Physical Therapy? ________________________________________________________________________

Right now, I feel I am getting (circle) Better Worse Staying the same

Patient Signature:

Date: